Community Development Approaches to Health Promotion
In this literature review, it has become apparent that there are problems with definitions at every turn. What is Health Promotion? What is community? What is Community Development? What are community development approaches to health promotion?
It is also clear that the policy environment has progressively moved, both nationally and internationally, towards a policy of community development approaches – accelerated since the adoption of the Ottawa Charter (and its 5 Principles) in 1986.
However, the translation of policy into practice has proved problematic, and solutions to these problems are still in development.
The first part of this review attempts to extract some definitions which can set the way to understanding this process, and briefly visits the policy environment.
The second part lifts abstracts from the literature in order to address the questions of community development approaches to health promotion, the need and barriers, looks at the problems of defining effectiveness or success of interventions, suggests requisites necessary in designing or implementing any community development approach, and finally briefly discussing the issues of empowerment and partnership.
It must be emphasised that these are weighty issues, and the time allocated has not allowed for detailed analysis. Rather, the abstracts, sometimes repetitive, have been extracted and placed in an order that can begin to make some sense although this process is in no way complete.
Today people believe that they are all healthy. Later, when there are any variations in regard to their health condition, they got shocked. People are not foreseeing how their health affects in every aspect of everyone’s life. In this essay we will describe health promotion of health and its principle. Further it will explain the roles of nurses in promotion of health. The health promotion is ...
1. What is Health Promotion? Page 1
2. Approaches to Health Promotion – Page 3
3. Policy Environment – Page 6
4. Community Development Approaches to Health Promotion – Page 7
4.1 What is Community? – Page 8
4.2 What is Community Development? – Page 8
4.3 What are Community Development Approaches to Health Promotion? (Literature Abstracts) – Page 9
4.4 Lack of Evidence re Community Development Intervention Outcomes – Page 14
4.5 Difficulties in defining success or effectiveness – Page 16
4.6 Some examples of Community Development Approaches to Health Promotion – Page 17
5. Any Community Development Approaches to Health Promotion must have the following elements – Page 29
6. Questions of Community Empowerment & Partnership – Page 40
1. What is Health Promotion?
“McKinlay tells the story: He was sitting by the river one nice sunny day when he heard a shout and saw someone in the middle of the river clearly struggling to stay afloat. He dived in and rescued them . they had taken in a fair bit of water so required resuscitation, which he duly performed. Just as that person was ok, he heard another shout and lo and behold another person was in trouble. Of course he dived in and rescued that person too. Just as they were coming around, another shout! A third person had to be rescued. This went on for some time until he became exhausted and started to think about what was going on upstream that was causing all these people to end up in the river in such distress. So he headed up for a look. This is, in essence, what health promotion is. Of course people need to be rescued and brought back to full health BUT someone also needs to go upstream and figure out why there are so many people needing to be rescued.” 
Health Promotion occurs upstream with the aim of preventing people falling in or being pushed. Downstream we have secondary (aim to detect disease early so that treatment can be started before irreversible damage occurs e.g. screening), and tertiary prevention and health care (management of established disease e.g. to minimise disability and prevent complications e.g. foot care for people with diabetes).
Mid-stream we have primary prevention and health care, usually individual, for example attempts to reduce risk of contracting disease (educating smokers, vaccinating).
Health promotion today is often confused with health education. When nurses are implementing health promotion in practice, an understanding of what health promotion is must be identified. According to the World Health Organization, health promotion is defined as, “the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus of individual behavior ...
And upstream we have health promotion including social policies and health promotion programmes, such as taxes on tobacco, smoke free legislation and advertising bans. This may include health education, which aims to reduce ill-health and increase positive health influencing people’s beliefs, attitudes and behaviour. Health Promotion has a dual role to prevent ill health and promote positive health. [25, 32]
“Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.” [Ottawa Charter for Health Promotion, First International Conference on Health Promotion, Ottawa, 21 November 1986 – WHO/HPR/HEP/95.1] 
A refined definition might be, “health promotion is the process of enabling individuals and communities to increase control over the determinants of health and thereby to improve their health.” Among other things, this definition suggests that in our efforts to evaluate health promotion efforts, we should obtain evidence on process as well as outcome, on the empowerment of individuals and communities, on the interventions directed at the “determinants of health” and on positive health outcomes as well as the prevention of negative ones. It also implies that we might consider using the evaluation process itself as a means to improve the capacities of individuals and communities to increase control over the determinants of health. 
Another refining definition, “health promotion is about helping people to have more control over their lives, and thereby improve their health. It occurs through processes of enabling people, advocacy, and by mediating among sectors. In essence, health promotion action involves helping people to develop personal skills, creating supportive environments, strengthening communities, influencing governments to enact healthy public policies, and reorientating and improving health services.” 
... disciplinary development. However the purpose of Health Promotion is to enable people to increase control over, and to improve, their health and its determinants. This is ... health promotion tend now to be seen as overlapping spheres’ Health promotion advanced this idea to allow health practitioners to work with communities to target specific health ...
• Health promotion involves the whole population in the context of everyday life
• Control or Empowerment
• Promoting Wellbeing (rather than dealing with “illness”)
• Building capacity
• It’s a process not just an outcome
• Directed towards action on determinants or causes of health/disease. Wide definition of determinants of health.
• Community Development
Put another way:
• aims to gain effective public participation
1. • aims to:
1. • create a supportive environment
2. • build healthy public policy
3. • strengthen community action
4. • develop personal skills
5. • empower local people
6. • improve equity and inequality
7. • re-orientate health service
8. • advocate for health 
Three words describe the role of practitioners involved in integrated health promotion programs:
• Enable: Integrated health promotion focuses on achieving equity in health. A major aspect of the work of integrated health promotion is to provide the opportunities and resources that enable people to increase control over and improve their health. This includes developing appropriate health resources in the community and helping people to increase their health knowledge and skills, to identify the determinants of their own health, to identify actions by themselves and others, including those in power, that could increase health, and to demand and use health resources in the community.
• Advocate: Action for health often requires health workers to speak out publicly or write on behalf of others, calling for changes in resources, policies and procedures. The Cancer Council lobbying for a ban on smoking in all enclosed spaces is an example, as is a local community health worker writing letters to the local paper calling on the council to improve facilities for physical activity for older people.
The Term Paper on QCF Level 2 Health and Social Care Diploma Group A: Mandatory Units Knowledge Workbook
Identify the different reasons people communicate. People communicate to express needs,feelings,ideas,ask questions,share experiences Explain how effective communication affects all aspects of own work Effective communication helps to understand client’s needs Explain why it is important to observe an individual’s reactions when communicating with them Because I can know from the reactions ...
• Mediate: Many sectors of the community, such as government departments, industry, non-government organisations, volunteer organisations, local government and the media take action that has an impact on people’s health, sometimes acting to support one another, sometimes disagreeing about what should be done. Health workers play a role in mediating between these different groups in the pursuit of health outcomes for the community, or in mediating between the health requests of different sectors of the community. 
2. Approaches to Health Promotion
How can one go about “doing” health promotion?
The following strategies, which are often combined, are commonly used:
• Creating supportive environments: Activities aimed at establishing policies that support healthy physical, social and economic environments (WHO, 1998).
• Health education: Consciously constructed opportunities for learning designed to facilitate changes in behavior towards a predetermined goal, and involving some form of communication designed to improve health literacy, knowledge, and life skills conducive to individual and community health (PAHO, 1996; WHO, 1998).
• Health communication: A strategy to inform the public about health concerns and place important health issues on the public agenda achieved through the use of the mass and multimedia, and other technological innovations that disseminate useful health information to the public, increase awareness of specific aspects of individual and collective health, as well as increase awareness of the importance of health in development (WHO, 1998).
• Self-help: Actions taken by lay persons to mobilize the necessary resources to promote, maintain or restore the health of individuals or communities through self-care activities such as self-medication, self-treatment and first aid in the normal social context of people’s everyday lives (WHO, 1998).
... A definition of mental health promotion involves “any action to enhance the mental well-being of individuals, families, organisations or communities” (DOH, p.27, 2001) The ... health promotion, many issues affecting mental health lies outside the remit of the health and social service, such as employment, social inclusion and neighbourhood renewal and health ...
• Organisational development: A process typically used in industry although applicable to other settings such as communities, to improve performance, productivity and morale issues, and attain an optimally functioning organization, with a high level of cohesion, well-being and satisfaction on the part of all those involved (Raeburn & Rootman, 1998).
• Community development / action: A process of collective community efforts directed towards increasing community control over the determinants of health, improving health and becoming empowered to apply individual and collective skills to address health priorities and meet respective health needs (WHO, 1998).
• Healthy public policy: Formal statements that demonstrate concern for heath and equity and which make healthy choices possible or easier for citizens, through creating supportive social and physical environments that enable people to lead healthy lives (PAHO, 1996; WHO, 1998).
• Advocacy: A combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or program (PAHO, 1996; WHO, 1998).
• Research: Information which links theory and practice through the investigation of the real world and which is informed by values about the issue under investigation, follows agreed practices, is sensitive to ethical implications, asks meaningful questions and is systematic and rigorous (Naidoo & Wills, 1998).
Evaluation research is formal or systematic activity, where assessment is linked to original intentions and is fed back into the planning process (Naidoo & Wills, 2000).”
• Medical approach: Focused on disease and biomedical explanations of health. Narrow concept of disease (ignore social/environmental dimensions) e.g. immunisation, screening [55, 25]
Examples of approaches to health promotion (Ewles & Simnet, 1995) 
|Aim |Appropriate Method |Example – Smoking |
|1. Health awareness goal |talks |Encourage people to seek early detection and |
|Raising awareness, or consciousness, |group work |treatment of smoking-related disorders |
The investigation of the reasons by which volunteers involve themselves on specific organizations, and actually stay for a long period of time, or leave groups which they became a part of is the theme of this article. The researcher wanted to provide an explanation that will cover the queries on volunteerism including its effects on the lives of the volunteers, importance in our current society, ...
|of health issues |mass media | |
| |displays and exhibitions | |
| |campaigns | |
|2. Changing attitudes and behaviour |group work |Persuasive education to prevent non-smokers |
|Changing the lifestyles of |skills training |from starting and persuade smokers to stop |
|individuals |self help groups | |
| |one-to-one instruction | |
| |group or individual therapy | |
| |written material | |
| |advice | |
|3. Improving knowledge |one-to-one teaching |Giving information to clients about the |
|Providing information |displays and exhibitions |effects of smoking. Helping them to explore |
| |written materials |their own values and attitudes and come to a |
| |mass media |decision. Helping them to learn how to stop |
| |campaigns |smoking if they want to |
| |group teaching | |
|4. Self empowering |group work |Clients identify what, if anything, they want |
|Improving self-awareness, |practising decision-making |to know about it |
|self-esteem, decision-making |values clarification | |
| |social skills training | |
| |stimulation, gaming and role play | |
| |assertiveness training | |
| |counselling | |
|5. Societal/environmental change |positive action for under-served groups |No smoking policy in public places. Cigarette |
|Changing the physical or social |lobbying |sales less accessible, especially to children;|
|environment |pressure groups |promotion of non-smoking as social norm. |
| |community development |Banning tobacco advertising and sports |
| |community-based work |sponsorship |
| |advocacy schemes | |
| |environmental measures | |
| |planning and policy making | |
| |organisational change | |
| |enforcement of laws and regulations | |
Integrated health promotion service delivery can be organised from one or more different angles, depending on the key priorities identified and the problem definition, including:
• health or disease priorities, for example, mental health, heart disease, diabetes, oral health
• lifestyle factors, such as physical activity and nutrition, tobacco use, safe sex
• population groups, for example, culturally and linguistically diverse groups, same-sex attracted youth, adolescents, older people living alone
• settings, for example, health promoting schools, health promoting workplaces, health promoting hospitals, council estates.
The key requirement for quality practice is how programs are planned, delivered and evaluated. By definition, quality practice is:
• enabling it is done by, with and for people, not on them; it encourages participation
• involves the population in the context of their everyday lives, rather than focusing just on the obvious lifestyle risk factors of specific diseases
• directed to improving people’s control over the determinants of their health
• a process – it leads to something, it is a means to an end. 
3. Policy Environment
In 1979, the thirty-second World Health Assembly launched the Global Strategy for health for all the year 2000 thereby endorsing the Report and Declaration of the International Conference on Primary Health care, held in Alma-Ata, USSR in 1978. The commitment to the achievement of “Health for All by the Year 2000” was accepted by the 150 member states and became the basis of all the WHO – related new developments in the field of health care in the world. A modern movement termed Health Promotion emerged out of the historical need for a fundamental change in strategy to achieve and maintain health. The Health Promotion Programme at the regional office for Europe of World Health Organisation (WHO) was established in 1984 bringing to fruition the objectives outlined in the policy documents that the Regional Office for Europe had developed over the previous five years.
The first International Conference on Health Promotion met in 1986 in Ottawa to present a charter for action in order to work towards the achievement of Health for All by the Year 2000 and beyond. The action plan of the 1986 Ottawa Charter advises that health promotion strategies and programmes should be adapted to the local needs and possibilities of individual countries and regions to take account of differing social, cultural, political and economic systems. The declaration and programme for action is predicated upon the fundamental prerequisites for health i.e. peace, shelter, education, food, income, sustainable resources, a stable ecosystem, social justice and equity. At the heart of this health promotion action programme lies the key concerns with advocacy, enablement and mediation.
Identification of priority issues is only one dimension of the Ottawa Action plan. The role of those engaged in health promotion is to put into effect, within an integrated philosophy, these following aspects of the health promotion action programme:
i) Endeavouring to build a healthy public policy
ii) Working to create supportive environments
iii) Helping to strengthen community action in various settings
iv) Striving to develop personal skills
v) Working together to re-orientate Health Services 
Ottawa Charters Five strategies
The 1997 World Health Organisation (WHO) Jakarta Declaration on Health Promotion into the 21st Century explicitly acknowledges the demonstrated effectiveness of health promotion in the following statement: Health promotion makes a difference. Research and case studies from around the world provide convincing evidence that health promotion works. Health promotion strategies can develop and change lifestyles, and the social, economic and environmental conditions which determine health. Health promotion is a practical approach to achieving greater equity in health. There is now clear evidence that:
Comprehensive approaches to health development are the most effective – those which use combinations of the Ottawa Charter’s five strategies are more effective than single track approaches.
Settings offer practical opportunities for the implementation of comprehensive strategies – these include mega-cities, islands, cities, municipalities, and local communities, their markets, schools, workplaces, and health care facilities.
Participation is essential to sustain efforts – people have to be at the centre of health promotion action and decision- making processes for it to be effective.
Health learning fosters participation – access to education and information is essential to achieving effective participation and the empowerment of people and communities.
These strategies are core elements of health promotion and are relevant for all countries (WHO, 1997).
The theoretical drive for WHO’s action programme is based upon a shift in emphasis from issues to settings. The shift has been from infectious diseases to behavioural diseases and risk factors followed by an increasing emphasis on the environmental factors that create and maintain health. The aim now is to influence the context of health actions and make the social and physical environment supportive to health and to provide individuals with strategies of health improvement and maintenance that can be integrated with meaning into a person’s overall life pattern. 
Improving health and reducing health inequalities are now cross-cutting UK Government priorities, with national targets agreed by various departments (public service agreements), as part of the Government Intervention in Deprived Areas (GIDA).
There are now unprecedented national policy drivers to involve communities in local decision-making across sectors. 
1999 Saving Lives: Our Healthier Nation is a comprehensive government-wide public health strategy for England. Its goals are to improve health and to reduce the health gap (health inequalities).
The strategy aims to prevent up to 300,000 untimely and unnecessary deaths by the year 2010. Targets, including health inequalities, will be tailored to local needs through needs assessments in association with local authorities.
2004 Choosing Health: Making healthy choices easier is a government white paper, which sets out the key principles for supporting the public to make healthier and more informed choices in relation to their health. 
4. Community Development Approaches to Health Promotion
4.1 What is Community?
The US Government 2010 Healthy People report defines community as a specific group of people, often living in a defined geographical area, who share a common culture, values and norms, and who are arranged in a social structure according to relationships the community has developed over a period of time (World Health Organization, 1998; US Department of Health and Human Services, 2000).
Members of a community gain their personal and social identity by sharing common beliefs, values and norms which have been developed by the community in the past and may be modified in the future. They exhibit some awareness of their identity as a group, and share common needs and a commitment to meeting them. [1, 28]
4.2 What is Community Development?
Community development seeks to empower individuals and groups of people, with the skills they need to advocate on their own behalf, improve their lives, and provide communities with access to resources. 
Or put another way….
Community development, in very simple terms, is the process of developing social capital. It is a process that emphasises the importance of working with people as they define their own goals, mobilise resources, and develop action plans for addressing problems they have collectively identified. 
Definition of social capital (Putnam 1993): The community cohesion resulting from high levels of civic identity and the associated phenomenon of trust, reciprocity and civic engagement. Four characteristics: the existence of community networks, formal or informal, civic engagement (particularly in networks), local identity and a sense of solidarity and equality with other community networks, and norms of trust and reciprocal help and support. 
Social capital and community development:
Participating in social and civic activities, such as community group meetings, child care arrangements with neighbours, neighbourhood watch schemes and voting, all work to produce a resource called social capital. Social capital is critical to the health, wealth and wellbeing of populations.33 It is a key indicator of the building of healthy communities through collective and mutually beneficial interaction and accomplishments.34 Recent research has linked these types of activities to improved health outcomes.35, 36, 37, 38 
[33. Putnam, R. (1993), Making Democracy Work, Princeton University Press, Princeton, New Jersey.
34. Baum, F., Palmer, C., Modra, C., Murray, C. and Bush, R. (2000), ‘Families, social capital and health’, in Winter, I. (ed.), Social Capital and Public Policy in Australia, Australian Institute of Family Studies, Melbourne.
35. Berkman, L. and Syme, S. (1979), ‘Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents’, American Journal of Epidemiology, vol. 109, no. 2, pp. 186–203.
36. Kawachi, I., Kennedy, B., Lochner, K. and Prothrow-Smith, D. (1997), ‘Social capital, income inequality, and mortality’, American Journal of Public Health, vol. 87, no. 9, pp. 1491–8.
37. Baum, Palmer, Modra, Murray and Bush, op. cit.
38. Kawachi, I., Colditz, G., Ascherio, A., Rimm, E., Giovannucci, E., Stampfer, M. and Willet (1996), ‘A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA’, Journal of Epidemiology and Community Health, vol. 50, pp. 245–51.]
The notion of social capital represents a way of thinking about the broader determinants of health and about how to influence them through community-based approaches to reduce inequalities in health and wellbeing.39 A focus on social capital supports a balance of strategies that address behaviour and those that focus on the settings in which people live, work and play. The implication for integrated health promotion is that more emphasis is needed on efforts to strengthen the mechanisms by which people come together, interact and, in some cases, take action to promote health. Simple measures, such as providing space for people to meet, may be as health promoting as providing health information in an effort to change behaviour. 
[39. Gillies, P. (1998), ‘Effectiveness of alliances and partnership for health promotion’, Health Promotion International, vol. 13, no. 2.]
Service providers can also enhance the social capital within a community by supporting community projects that bring neighbours together to achieve a mutually beneficial goal, such as beautifying the environment of a public housing estate, establishing a community fruit and vegetable garden or working with the local sporting club to encourage all parts of the community to participate in sporting activities. 
4.3 What are Community Development Approaches to Health Promotion? (Literature Abstracts)
The evidence suggests that there has been a shift to looking at the social, economic, political, and environmental determinants of health because other methods of ill-health reduction have failed.
Therefore, the argument goes, it is necessary to develop communities themselves to take control of their own health agenda to tackle these health issues from the source.
However, developing communities brings its own problems; problems of definition; and tensions between the various agenda setters and resource holders.
The suggestion is, in much of the literature, although not clearly proven, that the only way left to go forward is community development, and some writers suggest that partnerships can be and need to be forged between communities, health service providers, and academics.
Below are some abstracts from the literature review, theorising about community development approaches and its barriers. This is followed by a discussion on the lack of comparable evidence and the difficulty in defining effectiveness or success in looking at interventions; some examples of specific interventions; a discussion of what community development approaches should or must include; and finally some notes on empowerment and partnership.
Again there is a problem of definition:
Community Development: the process by which a community identifies its needs, develops an agenda with goals and objectives, then builds the capacity to plan and take action to address these needs and enhance community well-being.
Community Organisation: the process of involving and mobilising major agencies, institutions and groups in a community to work together to coordinate services and create programmes for the united purpose of improving the health of the community:
Community-based: the process of agency development of solutions for health problems which incorporate community consultation and input thus allowing adaptation of the implementation to suit local needs/circumstances. 
A Community Development approach to health … is a process by which a community defines its own health needs to bring about change. The emphasis is on collective action to redress inequalities in health and enhance access to health care.
(Community Development and Health Network, Northern Ireland) 
[Northern Ireland is one area where Community Development Approaches have been adopted strongly]
Social, political, economic and environmental determinants of health
“Recent epidemiological analysis of health, disease and disability in the populations of most developed countries confirms the role of social, economic and environmental factors in determining increased risk of disease and adverse outcomes from disease. 
Health status is influenced by individual characteristics and behavioural patterns (lifestyles) but continues to be significantly determined by the different social, economic and environmental circumstances of individuals and populations. 
Through the Charter, health promotion has come to be understood as public health action which is directed towards improving people’s control over all modifiable determinants of health. This includes not only personal behaviours, but also the public policy, and living and working conditions which influence behaviour indirectly, and have an independent influence on health. 
(This more sophisticated approach to public health action is reinforced by accumulated evidence concerning the inadequacy of overly simplistic interventions of the past. To take a concrete example, efforts to communicate to people the benefits of not smoking, in the absence of a wider set of measures to reinforce and sustain this healthy lifestyle choice, are doomed to failure. A more comprehensive approach is required which explicitly acknowledges social and environmental influences on lifestyle choices and addresses such influences alongside efforts to communicate with people. Thus, more comprehensive approaches to tobacco control are now adopted around the world. Alongside efforts to communicate the risks to health of tobacco use, these also include strategies to reduce demand through restrictions on promotion and increases in price, to reduce supply by restrictions on access (especially to minors), and to reflect social unacceptability through environmental bans. This more comprehensive approach is not only addressing the individual behaviour, but also some of the underlying social and environmental determinants of that behaviour.) 
Insufficiency of education alone
It is now well understood from experiences in addressing specific public health problems of tobacco control, injury prevention and prevention of illicit drug use, and the more general challenge of achieving greater equity in health, that education alone is generally insufficient to achieve major public health goals. 
“More recently, researchers have called for a renewed focus on an ecological approach that recognises that individuals are embedded within social, political and economic systems that shape behaviors and access to resources necessary to maintain health. 
Such an approach corresponds with increased interest in understanding the complex issues that compromise the health of people living in marginalized communities. Emphasis has also been placed on the need for expanded use of both qualitative and quantitative research methods (e.g. Israel et al); greater focus on health and quality of life; and more translation and integration of basic, intervention, and applied research. 
Greater community involvement in processes that shape research and intervention approaches, e.g., through partnerships between academic, health services and community-based organisations is one means towards these ends. 
Community development and health
“Essentially, community development work acknowledges that health is as affected by the social conditions of people’s lives such as damp housing, unemployment, or poor access to facilities, as it was by lifestyle choices. Major policy documents including Towards a Healthier Scotland (1999) and Our National Health (2000) highlight the importance of considering life circumstances alongside lifestyle choices and disease in promoting health and wellbeing. 
A World Health Organisation (WHO) position paper (1991) directly linked community participation to empowerment as a means in itself of promoting healthier individuals and environments. Furthermore, research has recognised the significance of powerlessness and empowerment to the health of individuals and communities (Wallerstein 1993).
The concept of healthy communities as developed by the WHO regards active community participation as essential to creating healthy communities:
“The formation of local social capital can thus lead to the promotion of shared values and a common vision, integrated planning and resource utilization, and ultimately to systemic change.” (Murray, 2000, p101) 
There is a growing body of literature showing that being part of a social network of contacts is protective for health (Fisher 2001).
The effects derive from improved self-esteem, trust and increased feelings of being in control. 
Community Development Issues
“Current health promotion policy and practice places a high value on community development work because it aims to enable communities to identify problems, develop solutions and facilitate change. 
The overt ideological agenda of community development is to remedy inequalities and to achieve better and fairer distribution of resources for communities. This is achieved ideally through participatory processes and bottom-up planning. Empowering communities to have more say in the shaping of policies influencing health represents a break with earlier traditions of public health associated with top-down social engineering. 
However, community development means different things to different people and can operate on different levels (See Arnstein’s ladder, 1971).
Community development has, for example, been linked to community organisation, community-based initiatives, community mobilisation, community capacity building and citizen participation. 
There is, however, a common understanding of core principles, which inform community development work, two of which are participation and empowerment. These principles can and are, however, operationalised differentially in different types of community development work. 
Despite consensus that community participation should engender active processes involving choice, and the potential for implementing that choice, implementation has proven difficult. For example, when formal health services adopt an empowerment framework, their formal structures are not necessarily conducive to participation. 
Although it is commonly agreed that appropriate leadership and effective organisational structures are crucial to successful community participation, this requires a political climate that nurtures and facilitates the approach. 
“Community development uses a variety of methods and activities such as self help work, outreach, local action groups, lobbying, peer work, festivals and events, information, advocacy, group work, network building and pump priming community initiatives with small grants. 
The key characteristic of community development is that it starts from the experiences and perspectives of communities. In terms of health, local people need to be enabled or supported to identify the factors that impinge on their health and the solutions. It is argued that genuine participation is only possible when there is involvement in decision-making and evaluation. 
Community development approaches challenge the definition of health as an individual problem for which there are individual solutions, and health care systems that treat the symptoms and not the root causes of ill health. Instead, such approaches emphasise the knowledge and expertise of individuals and communities living through an experience and the centrality of drawing on this source of expertise to define problems and solutions and ultimately to design more effective services. The main benefits of community development approaches have been summarised as:
• Improving networks in a community, which has been shown to have a protective effect on health.
• Identifying health needs from users’ point of view, in particular disadvantaged and socially excluded groups.
• Change and influence, as it enhances local planning and delivery of services.
• Developing local services and structures that act as a resource.
• Improving self-esteem and learning new skills that can aid employment.
• Widening the boundaries of the health care debate by involving people in defining their views on health and local services.
• Tackling underlying causes of ill health and disadvantage. 
Health Inequalities, CBPR & Community
There is increasing empirical evidence that a complex set of contextual factors (including social, economic and physical environmental factors, such as poverty, air pollution, racism, inadequate housing, and income inequalities) play a significant role in determining health status. These factors contribute to the disproportionate burden of disease experienced by marginalised communities. There is also considerable evidence suggesting that numerous resources, strengths and skills exist within communities (e.g. supportive interpersonal relationships, community-based organisations) that can be engaged in addressing problems and promoting health and well-being. This understanding of the factors associated with health and disease has contributed to calls for more comprehensive and participatory approaches to public health research and practice, and a rise in partnership approaches, variously referred to as “participatory action research’ ’, “participatory research’ ’, “action research’ ’, and “community-based research’ ’. Policy changes at the organizational, community and national levels are needed to help address barriers and challenges to the adoption of such approaches and to support their increasing use. 
Challenges of community development
The community development approach encounters particular challenges in the context of health care. While support for the idea of extending community development approaches into mainstream health services and other public services has grown, in reality organisations are not always receptive to the idea of a longer term ongoing dialogue which might lead to major changes within the organisation or into areas that the organisation had not previously considered. The conclusion of a DHSS (Northern Ireland) (1999) document was that community development is still at a relatively early stage of development within mainstream agencies. It found most NHS Trusts and Boards did not have a stated policy for a community development approach, and there was a lack of focus for this work and few instances of training for staff in this area. 
The way of working with and not just on behalf of individuals and communities that is central to the community development approach, sits uneasily with traditional western medicine and the ‘medical model’ in which professionals know what the problem is as well as the solution. The challenge is not to the value of medical expertise per se, but rather to its dominance in respect of health knowledge and the allocation of resources. 
Few health service professionals are fluent with community development approaches and ways of working with, rather than on behalf of, people. In describing a public health programme set up to link new mothers with experienced mothers and Public Health Nurses in Ireland during the 1980s, Johnstone (1993) concluded: “Familiarisation of all health care workers with changes in policy and the background of research and development and aims of policy would eliminate some of the frustrations and create a more supportive environment…The community based approach has proved more effective in achieving change where this is indicated and is likely to be a more useful model for empowerment and self-care then the traditional type of health care approach.” (p255) Subsequently, Johnstone (1993) advocated that the education and training of health care workers should include the possibility of working in partnership with people rather than for people. Community and user groups and health and social services professionals need to perceive each other interacting in different sets of roles and relationships. McKnight (2001) also highlighted core differences between the shape and function of communities and service systems: communities were based around individuals and families, informal relationships, as well as formal groups, and relationships defined by choice. Service systems on the other hand, had hierarchical structures designed to ensure “a few people could control a lot of people” to produce goods or services. Such structures ensured uniformity and that goods and services met the same standards. Each kind of structure has its own (very different) rationale, ways of working and communicating, and the two kinds of system therefore often find it very difficult to engage constructively together. The central concern identified by McKnight (2001) was that of ensuring people were at the centre and influencing what happens. 
“Although there is general agreement about the complex interplay among individual-, family-, organizational-, and community-level factors as they influence health outcomes, there is still a gap between health promotion research and practice. The authors suggest that a disjuncture exists between the multiple theories and models of health promotion and the practitioner’s need for a more unified set of guidelines for comprehensive planning of programs. 
4.4 Lack of Evidence re Community Development Intervention Outcomes
“For the purposes of this review, researchers defined an intervention as an organized and planned effort to change individual behavior, community norms or practices, organizational structure or policies, or environmental conditions.” 
“Despite the fact that community development approaches have been used by several of the major community-based heart health initiatives, evidence of their use and usefulness remains sparse.” 
“The health effects of social interventions have rarely been assessed and are poorly understood. Studies are required to identify the possible positive or negative health impacts and the mechanisms for these health impacts. The assessment of indirect health effects of social interventions draws attention to competing values of health and social justice” 
“The Working Group also debated what is meant by “evidence” in the context of health promotion, with several members arguing that the concept of “evidence” may in fact be an inappropriate one in this context. One of the key arguments for this position is that the concept of “rules of evidence” in science tends to be related to particular disciplines, and since health promotion is by nature “multi-disciplinary,” it is not clear whose rules of evidence it should follow. However, most members of the group felt that it was impractical to take this stance given the fact that relevant policymakers, including members of the World Health Assembly, were demanding “evidence-based” health promotion. Several members suggested that it would be prudent if, at least for the time being, we accept the use of the term “evidence” within health promotion. As suggested by Keith Tones, perhaps the best way to think of it is within a judicial paradigm: “We should assemble evidence of success using a kind of ‘judicial principle’ – by which I mean providing evidence which leads to a jury committing [itself] to take action even when 100% proof is not available.” This approach has several advantages: it is a concept of “evidence” which most people can understand, it provides scope for considering a broad range of sources and types of evidence, it implies that evidence differs in quality and it implies that one must take the “weight of evidence” into account. However, this approach does not give us any guidance regarding what evidence is needed in the context of health promotion.” 
“Health outcomes in populations are the product of three factors: (1) the size of effect of the intervention; (2) the reach or penetration of an intervention into a population and (3) the sustainability of the effect.(4).
There are few written accounts of the adoption of community development approaches within the fields of statutory health care, while there is a thriving literature about the community development approach to health (Jones, 1998).
This picture is bound to change as the emphasis on adopting community development approaches increases.” 
“There is a well recognised gap between research findings and the implementation of evidence based prevention strategies in community settings (McGinnis and Foege, 2000).
Research should inform community leaders or facilitate using proven intervention strategies in community environments. However, community leaders and health promotion experts suggest that a barrier to the adoption of research-based, efficacious interventions is that these strategies may not meet community needs (Green and Mercer, 2001).
Interventions may be too complex, difficult or costly to integrate with existing activities. Part of the problem may be researchers’ attempts to find the most efficacious program rather than a program that could be implemented and delivered with limited resources to many people.” 
“The low level of individual participation rates in studies that recruited from a representative targeted population raises questions about generalisability.” 
Intervention – Sport – evidence
“Despite a comprehensive search for literature relating to the effectiveness of policy interventions implemented through sporting organisations for promoting healthy behaviour change, no evidence in the form of well-designed and evaluated interventions was found. The ability to provide clear directions or strategies for future health promotion interventions is therefore limited. It is likely that these types of interventions are rarely evaluated or published, or that such evaluations are only available through contacting each sporting club, sporting association, health promotion agency or other agencies with a remit for sport (e.g. local councils).
An internet search identified a number of case studies in this area. These included post-data only, and evidence on outcomes was typically anecdotal. It is essential that sporting or health promotion agencies that conduct such interventions evaluate the interventions, publish the results and disseminate them widely. This will enable practitioners to more readily and the available evidence, and consequently, to implement effective interventions. In future, funding for evaluation should be built into sporting programs. However, as noted in the review by Payne (Payne 2003) there is a limited capacity to carry out evaluation in sporting organisations. Payne suggests that academic-based researchers should work in partnership with the sport and recreation industry to ensure that sporting programs are evaluated in a useful way. This may simply involve the introduction of data collection tools/databases in order to evaluate programs in a quasi-experimental manner. Practitioners therefore need to form relationships with the tertiary education sector.” 
“It is important to recognise that these conclusions are drawn from a wide range of research across many different issues. Establishing evidence for the effectiveness of interventions dealing with specific issues, however, can be more problematic in some cases than for others, particularly in areas such as nutritional status and obesity which have complex and multifactorial etiologies and which require long time frames for measurable changes to occur. This must be taken into account in considering the material provided in this report.” 
Evidence mental health, healthy eating, and physical activity in schools
Findings: This synthesis identified good quality systematic reviews that covered mental health, aggressive behaviour, healthy eating, physical activity, substance use and misuse, driver education, and peer approaches. Reviews of programmes that promoted mental health in schools (including preventing violence and aggression) show these programmes to be among the most effective ones in promoting health. Of these programmes, the ones that were most effective were of long duration and high intensity, and involved the whole school. New reviews that focused on promoting healthy eating and physical activity confirmed an earlier review, which found that multifactorial interventions, particularly those involving changes to the school environment, were effective. Four new reviews of programmes that focused on promoting the prevention of substance use confirmed previous findings that these programmes are relatively ineffective. Also, programmes on preventing suicide reduced suicide potential, depression, stress and anger, but less rigorous studies suggested a potential harmful effect in young males. In some (but not all) studies, peer-delivered health promotion was found to be effective, compared with teacher-led interventions, and this approach was highly valued by the young people involved. The systematic review, which evaluated health outcomes of programmes that used elements of the health promoting schools approach, included small studies of variable quality. It found apparent benefits to the social and physical environment of the school, and some studies found the programmes benefited health-related behaviour (dietary intake and physical fitness).
No reviews evaluated the cost–effectiveness of the programmes or interventions.” 
There is a clear lack of comparative data in measuring effectiveness of different approaches to health promotion.
4.5 Difficulties in defining success or effectiveness
Definition of goals of intervention (what to measure)
“Reach is defined as the percent of potentially eligible individuals who participate in the intervention study, and how representative they are of the target population from which they are drawn. Efficacy/effectiveness is the intended positive impact of the intervention and its possible unintended consequences on quality of life and related factors. Reach and efficacy/effectiveness operate at the individual level. Adoption is the percent of potential settings and intervention agents that participate in a study and how representative they are of targeted settings/agents. Implementation refers to the quantity and quality of delivery of the intervention’s various components. Adoption and implementation are setting-level dimensions. Finally, the maintenance dimension includes individual- and setting-level indices. At the individual level, maintenance is defined as the longer-term efficacy/effectiveness of an intervention. Outcomes at 6 months post-intervention contact reflect longer-term individual maintenance. The setting level definition of maintenance refers to the institutionalisation of a program and is assessed according to the percent of settings that continue the intervention program, in part or in whole, beyond the study duration (Glasgow et al., 1999; Glasgow et al., 2001).” 
“There is increasing evidence emerging regarding the effectiveness of community-based injury prevention programmes. The use of multiple interventions implemented over a period of time can allow injury prevention messages to be repeated in different forms and contexts and can begin to develop a culture of safety within a community. Important elements of community-based programmes are a long-term strategy, effective and focused leadership, multi-agency collaboration, the use of local surveillance to develop locally appropriate interventions and tailoring interventions to the needs of the community. Time is also needed to coordinate existing networks, and to develop new ones. However, a positive and sustained impact of community-based programmes on injury rates has not yet been demonstrated conclusively. There is a need to develop valid and reliable indicators of impact and outcome appropriate to community studies. Where proxy measures are used for injury outcomes, it is important that there is clear evidence of the association between the proxy (e.g. hazard removal, knowledge gain or behaviour change) and injury risk (Towner et al., 1996Go).
There is also an urgent need to develop and monitor indicators to assess and monitor a culture of safety, programme sustainability and long-term community involvement. Community-based injury prevention programmes have been hampered by the lack of resources allocated to both their programme development, and appropriate and rigorous evaluation.” 
“Health promoting schools and health promotion in schools: two systematic reviews
# Ensure that process evaluation which describes the way in which programmes have been implemented is undertaken and reported in all studies of health promotion in schools.
# Develop valid and reliable measures for evaluating the outcome of the health promoting school initiatives, particularly those measuring mental and social well-being for children and adults. Incorporate these in all studies of health promotion in schools.” 
4.6 Some examples of Community Development Approaches to Health Promotion
1. Community development, user involvement, and primary health care
Community development recognises the social, economic, and environmental causes of ill health and links user involvement and commissioning to improve health and reduce inequalities. Communities can be geographical—such as particular housing estates—or communities of interest, such as user groups. Trained community development workers bring local people together to:
* identify and support existing community networks, thus improving health;
* identify health needs, in particular those of marginalised groups and those suffering inequality;
* work with other relevant agencies, including community groups, to tackle identified needs;
* encourage dialogue with commissioners to develop more accessible and appropriate services.
Many examples of these activities exist. Studies show that community support through social networks is protective of people’s health. High levels of trust and density of group membership are associated with reduced mortality. Conversely, lack of control, lack of self esteem, and poor social support contribute to increased morbidity.
Needs assessment that is focused on communities can identify solutions as well as problems. Results of such initiatives include a new post of youth health adviser to support youth centred health activities across practices in Lewisham, which has led to improved learning about contraception and sexual health, improved liaison with practices, and changes in practice provision to make services more appropriate for the young people they serve. In St Peter’s Ward, a deprived area of Plymouth, a community development approach has resulted in free pregnancy testing in a local community project, the setting up of a “parentwise” project that draws on resources within the community, changes in health visitors’ working, and the provision of more acceptable antenatal classes. The more involved the community is in needs assessment, the more likely changes are to ensue. These assessments can provide representative views, particularly if quantitative approaches are used to triangulate these views, and there is little evidence that patients make unreasonable demands.
Community development can also lessen the impact of poverty on health. In Torquay concern about nutrition has led to the setting up of a food cooperative managed by local people that makes available cheap, healthy food. Community development can reduce social exclusion by ensuring that marginalised groups influence health services. In Bradford such an approach increased the uptake of cervical and breast screening among women from ethnic minorities. Minority ethnic communities, disabled people, adolescents, and elderly people have all been involved in the commissioning process in Newcastle, where a community development worker, accountable to the community, brings together community groups with purchasers and providers to implement change.
Examples of community development interagency activity include the work of a safety group in Torquay which resulted in policy changes within the housing department, play areas, and other borough and police services. While health professionals prescribed drugs to patients in their hilly area in Lewisham, a community development solution was found through a new bus service. By involving the local authority, it was possible, in a single intervention, to respond in a practical way to issues of loneliness, isolation, and problems of exercise tolerance.” 
2. Outcomes of Community-based Participatory Research
Improved Research Quality Outcomes
When the EPC researchers looked at the influence of community involvement on the quality of interventional studies, they discovered 11 of the 12 completed intervention studies had reported enhanced intervention quality. Just two studies reported improved outcomes, while eight noted enhanced recruitment efforts, four reported improved research methods and dissemination, and three described improved descriptive measures. Very little evidence of diminished research quality resulting from CBPR was reported.
Community and Research Capacity
Of the 60 studies reviewed, 47 reported improved community involvement, including additional grant funding and job creation, as an outcome associated with the study. The authors—typically academics—generally focused on the increased capacity of the participant community, rather than that of the research community.
Among the 12 studies evaluating completed interventions that play a role in health outcomes, two dealt with physiologic health outcomes, three with cancer screening behavior, and four addressed other behavioral changes (including alcohol consumption, immunization rates, and safer sex behavior).
Finally, three studies measured the impact of the intervention on emotional support, empowerment, and employee well-being.
Given the highly varied health outcomes, measurement strategies, and intervention approaches used, the EPC researchers were unable to perform a direct comparison of studies and their relative impact on health outcomes. Moreover, an absence of cost-effectiveness data precluded any comparison of outcomes from CBPR studies and those of more traditional research studies.
Level of Community Involvement
Community involvement varied in different stages of the research. There was strong involvement in recruiting study participants, designing and implementing the intervention, and interpreting findings. Many authors argued that community involvement (especially in theses areas) leads to:
• Greater participation rates.
• Increased external validity.
• Decreased loss of follow up.
• Increased individual and community capacity.
The disadvantages of community involvement were not frequently reported, but they may include:
• The introduction of selection bias (bias in recruitment).
• Decreased (and sometimes an absence of) randomization.
• The potential selection of highly motivated intervention groups not representative of the broader population. 
3. Good Practice – Mental Health
From mid July 1998 to the end of May 1999, Auseinet provided seed funding and intensive support to eight agencies that provided services to children and young people to reorient an aspect of their service to an early intervention approach to mental health. The aim was to give the agencies the opportunity to build their capacity by developing a range of tailored, potentially sustainable strategies.
All agencies made workforce development the foundation of their reorientation process. As most of the agencies were not primarily mental health focused, enhancing the mental health literacy of staff was a vital first step in reorientation. They informed staff about the mental health issues faced by the young people who used their service, gave them the skills to recognise risk factors and early warning signs, and established procedures for appropriate referral. The training programs were documented to guide future training needs and to provide resources for staff.
All of the projects showed evidence of organisational development. Management support was demonstrated by the formation of steering committees, reference groups and umbrella groups. Policy development occurred within as well as between agencies. One project developed an early intervention policy outlining referral and support mechanisms and others developed recommendations for incorporating early intervention into new policies. Two projects developed formal interagency agreements and policies. The development of partnerships was one of the most successful aspects of the reorientation projects. Most of the agencies established new networks or strengthened existing ones by including guest speakers and staff from other agencies in their training programs. Several of the projects developed successful formal partnerships. Two of the larger projects were collaborations between influential agencies and had the resources to allow the projects to expand beyond their original scope. All of the agencies allocated resources to the projects and several of the larger agencies contributed additional funds to employ the reorientation officer full-time. After Auseinet funding had ceased, most of the agencies had allocated funds to sustain or expand the reorientation process or to take it in a new direction. 
Most agencies had sustained or expanded their early intervention activities two and a half years after the reorientation project. The extent of reorientation ranged from conceptual shifts in staff knowledge and increased awareness and identification of mental health problems, through to extensive implementation of mental health promotion, prevention and early intervention programs and the development of partnerships with other agencies and the community. In five of the eight agencies, further early intervention projects were conducted, the agencies were better able to detect mental health problems and target referrals, there was an increase in mental health awareness and literacy within the organisation and in the community, and increased support from the community. One agency noted that while the strategies developed in the reorientation project had not been sustained, the project had led to different ways of implementing early intervention activities and subsequent success with other projects. The remaining two projects noted a marked change in early intervention ways of thinking and referrals although they did not have the resources to continue concrete projects. Several of the agencies reported that the reorientation project had given them the confidence to undertake other projects or apply for further funding. Most of the agencies considered that the reorientation projects served as a useful platform from which to either begin or expand early intervention activities. 
“Most of the reorientation officers thought that the resources allocated to the project were insufficient and that they had insufficient time in which to achieve the objectives of the project. Several of the reorientation officers in the non-government agencies especially found their workload demanding because they were employed on a half-time basis. Some of the staff were initially reluctant to be involved in the reorientation projects because of their already heavy workloads. Generally, as staff became involved in the training they became more enthusiastic about the project and prioritised their time to enable greater involvement. 
“Many of the barriers identified in the original reorientation projects are still evident. High staff turnover rates are a reality in many agencies; therefore time and resources need to be devoted to training new staff in early intervention. The heavy workloads of staff remained an issue, although some of the agencies developed strategies to reframe rather than add to existing workloads. Most of the agencies felt that the sustainability of the projects was largely dependent on funding. Seed funding was perceived as being useful for platform activities, but all identified the marked need for more funding to sustain and expand early intervention activities. Many of the agencies reported that their involvement in the Auseinet project had helped them to secure funding from other sources. 
New barriers were identified at follow-up, when many of the agencies were applying early intervention approaches directly with clients. They often found it difficult to refer clients with early signs of mental health problems to mental health services because the latter typically function from a crisis intervention model. In addition, mental health services already have high demands on their services and are often not able to take on new referrals. 
4. Workplace Example
Beyond the organisation participating in the present study, it is hoped that individuals and groups involved in workplace health promotion can use the findings to help overcome two of the key barriers to adopting the health promoting settings approach. These barriers are: (i) a lack of information on the relationship between work characteristics and employee health; and (ii) not having the confidence or knowledge to identify and address organizational-level issues. Both qualitative and quantitative methods were employed in the audit, and the results revealed that there was a close relationship between several work characteristics and employee well-being. Workbased support, job control and time-related pressures were identified as three work characteristics that offer valuable opportunities for boosting the health-promoting value of the organization participating in the present study. 
5. Plenty of examples of large company workplace health promotion world wide
Model of good practice: The Shanghai Project Shanghai is the largest industrial city in China, with a population of over 13.5 million people. In collaboration with WHO, and supported by the Government of the People’s Republic of China, the Shanghai Municipal Health Bureau and the Shanghai Health Education Institute conducted a pilot workplace health-promotion project from 1993 to 1995. The project involved 21 613 workers in four workplaces: Wujing Chemical Complex, Shanghai Hudong Shipyard, Shanghai No. 34 Cotton Mill and Shanghai Baoshan Steel Company.
Based on data gathered through a baseline survey conducted in early 1993, and guided by members of the Shanghai Health Education Institute and an occupational health expert advisory reference group, each workplace developed, implemented and evaluated workplace health-promotion programs.
The project adopted an integrative model of workplace health promotion and sought to address identified organisational, environmental and behavioural factors that were negatively impacting upon the health of the workers. Health-promotion programs employed multiple strategies in line with the Ottawa Charter and sought to develop healthy policies and regulations, create safe and supportive environments, strengthen preventive health services, facilitate workers’ participation and educate workers to promote healthy behaviour. Initiatives undertaken included the establishment of health education and health-promotion committees, drafting and implementing workplace standards for identified occupational hazards, improved management of workplace sanitation and hygiene, and improved occupational health hazard monitoring and control (e.g. noise, dust and chemical leakage).
Other initiatives included the supply of nutritious foodstuffs and the reduction of salt in food in workplace canteens, planting trees and flowers, cigarette smoking and alcohol cessation programs, cervical screening and thorough follow-up treatments, improved preventive health services for workers, and greater worker participation in the identification and control of occupational hazards.
During the project, particular attention was given to such issues as staff mobilization and training, establishing co-ordinating and networking mechanisms, and regular consultation with workers, management and expert reference groups. These measures ensured that all interested parties were involved in the planning of the project and that they were given opportunities to participate in its implementation. Furthermore, there was an emphasis on multi-sectoral involvement and the integration of health promotion into management practices.
The project was closely monitored, and an evaluation carried out in 1995 showed excellent measurable outcomes, e.g.:
• reduced incidence of work-related injuries by 10–20%;
• reduced diseases and related health care costs (e.g. pharyngitis, from 16% to 10%);
• improved health and safety knowledge and practices (the use of safety devices or protective equipment increased from 20–30% to 70–90%);
• reduced risk behaviour (reduction of salt consumption, cigarette smoking);
• reduced levels of sick leave by 50%.
Other notable project achievements included: improved company image and management practices, a cleaner and safer workplace environment and work conditions, increased housing provision, recreation facilities and even transport in the case of the Hudong shipyard. Learning from this pilot project, the project team has since developed what they have proudly called the ‘Shanghai Model’ of workplace health promotion. The model’s four distinctive features are: comprehensive, integrative, a system of management and multi-sectoral networks, and a multiplicity of intervention strategies. Since then, the Shanghai Project team has developed draft Chinese language guidelines for workplace health promotion, and has been funded by the World Bank to work with 10 more workplaces.
Successful factors for workplace health promotion: Action and criteria models currently available point uniformly to the following factors as key indicators of a successful workplace healthpromotion initiative.
Participation: all staff must be involved in all phases. 
6. See Note 15. Public Health Division, Department of Human Services, Melbourne, Victoria, Australia
Health Promotion Strategies for Community Health Services. An Evidence-Based Planning Framework for Nutrition, Physical Activity, and Healthy Weight
Lots of examples of Nutrition, Physical Activity, and Healthy Weight Projects
7. Nutrition: Effective Components for Nutrition Interventions – Summary
In December of 1999, the Prevention Unit within the Division of Preventive Oncology at Cancer Care Ontario commissioned a review of international literature on nutrition interventions, in the areas of policy, programs and media. The purpose of the review, which included literature from January 1995-January 2000, was to consolidate existing knowledge of nutrition intervention effectiveness in order to inform the development of a nutrition and healthy body weight strategy for cancer prevention for the province.
Fifteen interventions studies were included in the review, 10 of which reported positive outcomes, and 5 reporting negative outcomes, in well-designed studies (i.e. controlled trials with or without randomization).
Among those reporting positive outcomes, five components were common:
1. • theoretically based (Sorenson, Glanz, Perry, Liquori, Nicklas, Forester)
2. • Involvement of the family as a source of support; (Sorenson, Glanz, Liquori, Perry, Coates, Havas)
3. • Use of participatory models for planning and implementing interventions; (Perry, Liquori, Havas, Nicklas, Sorenson, Glanz)
4. • Provision of clear messages for media campaigns; (Owen, Reger, Norum)
5. • Provision of adequate training and support to intervenors (Beresford, Perry, Liquori, Havas, Forester)
A number of lessons were learned by those reporting negative study outcomes including:
1. • Ensuring sufficient intensity and duration of the intervention to bring about change and behaviour maintenance. Repeated and on-going contact is necessary throughout the intervention including post follow-up (Glasgow, Resnicow, Kristal, Jeffrey)
2. • Making environments conducive to support behaviour change, in particular modification of food service policies for worksites and schools (Glasgow, Resnicow)
3. • Ensuring particpatory mechanisms for planning, such as steering committees and, (Glasgow, Resnicow)
4. • Delivering school-based interventions either before the school day begins or during school hours; afterhours results in lower attendance (Resnicow)
Intervention settings, such as schools, workplaces (Sorenson, Glanz) and health care institutions, offered prime channels to employ these principles, especially when developing and implementing interventions for large groups of people. Community settings work well for women whose learning is enhanced by a family friendly atmosphere. The review suggests that these settings should be regarded as ideal places to focus a nutrition intervention strategy within Ontario. The principles derived from this review equipped Cancer Care Ontario with the information necessary to develop a nutrition and healthy body weight strategy for the province of Ontario. This included establishing a reference group (known as the Ontario Collaborative Group on Diet and Cancer) with a mandate to link practitioners in the areas of policy, community and public health programs and research and use them as a reference group. The Unit took the lead in developing a program logic model for the overall strategy (with guidance from the Collaborative Group) and invested in developing a behavioural change pilot project “Take 5” to increase vegetable and fruit consumption among women with children under the age of 14, based on stakeholder feedback, and is currently being piloted. 
8. See Note 23 “Stories that can change your life: communities challenging health inequalities” (Health_Inequalities.pdf)
Lots of Good Practice Examples and Great Quotes from Southampton City PCT Ujala Health Project, Middlesbrough PCT Football Community Project, Blyth Valley Food Cooperative Limited, The Foyer Federation and health projects, Rotherham PCT Healthy Hearts Project, Easington PCT transport initiative, Northamptonshire Heartlands PCT Older Persons Health Forum, Thurrock PCT Community Mothers, Slough PCT Health Activists
9. Community development at strategic level
In the next few paragraphs, actual examples of the adoption of a community development approach in relation to health are documented.
Craigavon and Banbridge Community Health and Social Services Trust
At strategic level, there is increasing evidence that community development is seen to be an important part of any participatory strategy and more resources are gradually being diverted to this end. However, although the rhetoric is spreading, the change in attitudes and organisational re-arrangements are slower to gain ground. The Craigavon and Banbridge Community Health and Social Services Trust in Northern Ireland is an exceptional example of a Health Service Trust which has accepted that community development has to inform its whole approach. (SHF, 2001c; McShane and O’Neill, 1999)
The Trust accepted the contribution of community development to the core business of Health and Social Services by mainstreaming this approach across all its programmes of care. The importance of increasing community development awareness and skills for other managers and staff was also recognised and the Trust was actively committed to a training strategy. It viewed this as a core feature of implementing the Government’s strategy on social inclusion, social justice and partnerships for health and wellbeing. The Trust’s Community Development Unit has actively worked with different community groups, ensuring that broader aspects of health are highlighted. For instance, a Rapid Participatory Appraisal was conducted bringing together various parties such as nursing, community work, social work staff and local people. This enabled issues to do with housing, the local economy and community infrastructure to be included and worked at to improve the wellbeing of the community.
The Addiewell Project
One example of local communities becoming involved in setting the agenda around health was that of the Addiewell Task Group (Addiewell Research Project, 2000).
In a joint initiative between local residents, West Lothian Council and the University of Edinburgh, the Addiewell Task Group developed indicators and measures to do with health and wellbeing that were seen as important by the community. The Health Unit based within the local Council worked alongside local people to ensure their participation in the identification, definition and proposals for measuring health indicators. The work was founded on the principle that the best people to decide what issues and indicators were important were local people themselves.
Working together: Learning together
A two year training programme, Working Together: Learning Together, was set up as part of the Scottish Executive’s ‘Listening to Communities’ programme, to provide training in understanding social exclusion, partnerships and Working for Communities Pathfinders in Scotland. The programme aims to ensure that communities are involved in “genuine, meaningful partnership where they can exert real influence” (Working Together: Learning Together website – www.wtltnet.org.uk).
There are 60 partnerships and 900 people participating in training from agencies and communities led by a consortium of organisations including the Scottish Community Development Centre, Community Learning Scotland, the Scottish Council for Voluntary Organisations, the Poverty Alliance, and the University of Dundee. 
10. Nutrition: Database of International Nutrition Interventions
Includes Intervention Methodology, Evaluation Method, & Impact Achieved
“10. Nutrition education
10.1 General community nutrition programmes
10.2 Mass media nutrition education
10.3 School-based nutrition education”
11. Database of School-based interventions
Includes Intervention Methodology, Evaluation Method, & Impact Achieved
“Interventions using schools
12. Illicit drugs: effective prevention requires a health promotion approach
“There is an emerging evidence base for interventions that tackle particular risk and protective factors. In the USA, for example, the Midwestern Prevention Project, conducted by Pentz and co-workers, examined the effectiveness and replicability of a multi-component, community-based drug misuse prevention programme. The study looked at the effectiveness of school interventions in the context of broader community mobilization strategies. Significant reductions in tobacco and cannabis use occurred amongst students followed up at Years 9 and 10. However, training for community leaders and the use of mass media was less effective when not teamed with school-based and parenting programmes.
Another US study, Project Northland, led by Perry and colleagues, used similar school- and community-based approaches to reduce alcohol and other drug use in North West Minnesota. The research found statistically significant reductions in drug use, changed peer norms and improved parent–child communication. The case can be made from both of these studies for whole-community approaches that complement individual-focused interventions.
The Gatehouse project in Australia aims to reduce the rates of depression and self-harm amongst young people. This school-based programme emphasises the importance of positive connectedness between the individual and both teachers and peers. It has identified three priority areas for action: (i) building a sense of security and trust; (ii) enhancing skills and opportunities for good communication; and (iii) building a sense of positive regard through valued participation in aspects of school life. Drawing on the Ottawa Charter framework, the project aims to create a healthy environment rather than concentrating on individuals. Although still at an early stage, the project has already demonstrated a reduction in the rate of smoking in intervention schools compared with non-intervention schools.
When people become socially disconnected they may seek comfort and a sense of security through drug use, and find support and ready acceptance from other drug users. In the UK, particular emphasis has been placed on structural issues that exacerbate this problem, such as poor housing, low income, unemployment, poor education and high crime environments. Prime Minister Tony Blair has set up a Social Exclusion Unit within the Cabinet Office to focus on key points of transition when young people are at greatest risk of becoming excluded and marginalized. Action is centred on truancy, homelessness, neighbourhood renewal, teenage pregnancy, and opportunities for young people not in education, employment or training. Such ‘joined up solutions to joined up problems’ are very much at the centre of the Ottawa Charter’s healthy public policy domain.
In Australia, the Centre for Adolescent Health has recently completed a report on evidence-based approaches to promoting adolescent health. The work reviewed 178 research articles and assigned weightings to signify the confidence with which programmes can be implemented. The ‘best buys’ comprise a broad set of health promotion approaches, including health promoting schools, social marketing, peer intervention, parent support and community strengthening. The Victorian government, upon the advice of its Drug Policy Expert Committee, has endorsed these approaches and has announced that substantial funding, representing at least 10% of the total drug budget, will be allocated to prevention. Strategies are likely to include the following elements.” 
13. Community-based research: creating evidence-based practice for health and social change
“In the following section, three examples of community-based research are provided to demonstrate how community-based research generates evidence from practice.
James Bay Midlife Project (Hills, Mullett and Burgess, in progress).
This project was generated by a local community health centre in order to create a program for women that would maximize their participation in and control of making health decision in their midlife. The inquiry group consists of two university researchers from the Community Health Promotion Coalition, University of Victoria (the authors of this paper), program planners and staff from the James Community Health Project, and women of the community, including a physician, a homeopath, a naturopathic physician, an editor, teachers, counsellors and social workers. This group is in the process of generating evidence about ways of being that are “women-centred”. The group is exploring women-centred care in several different contexts such as education programs, support groups, physician/client interactions and informal groups. To date it has used a critical incident method to collect accounts from group members’ own experiences about what constitutes women centred care in midlife. Members subsequently conducted interviews, held focus groups or collected narrative accounts of their practice. The data is being analyzed, considered in light of former knowledge and new methods are being chosen to generate further evidence about how to practice in a way that is women-centred.
Making Connections: Nurturing Adolescent Girls’ Strengths (Bannister, in process)
This community based research project, funded by the British Columbia Health Research Foundation (BCHRF), was created in direct response to concerns articulated by adolescent girls who identified the importance of peer support and mentoring relationships as a means to enhance their ability to handle relationships. Effective relationships were viewed as the focal point for building self-esteem and enhancing health. A participatory action research (PAR) framework is being used to understand adolescent girls’ (ages 14-19) experiences of relationships and to facilitate action. Four groups of girls, each of which has direct links to an advisory committee, have been meeting weekly for 18 weeks. The advisory committee serves as a forum for the girls to present their health related concerns and to generate further action. The adolescent girls are involved in analyzing the data. The girls report that they are learning new ways of interacting, thereby enhancing their ability to handle relationships. In year two of the project, it is intended that the girls will use their learning and reflections to create action to influence policy-makers and practitioners who are working with adolescent girls.
Sharing Resources To Alleviate Scarce Resources
Several non profit organisations asked a researcher to work with them because of their concern about current funding structures that have created a competitive situation for non-profit agencies in the community – agencies that previously had worked together to resolve issues in order to sustain a healthy community. The methodology of co-operative inquiry (Heron, 1996; Reason, 1988) is being used to develop a model of inter-agency collaboration, a transformative model for practice that will afford community agencies the ability to evolve together within new funding contexts. A critical incident technique was the initial method by which the current successful and unsuccessful collaborative relationships were examined. By reflecting on their current practice, the members of the inquiry group not only have begun to articulate the essential components of a collaborative model but also have reported that their relations with each other have improved. Their emergent model, which is based on the experiential, representational, propositional and practical knowledge of those engaged in living the model, is significantly different from theoretical models, which tend to be reduced to administrative models.” 
14. Health Education Board for Scotland: Health promotion projects: mental health
“Health promotion projects list”
15. Mental Health Promotion
“The National Service Framework Standard One: Mental Health Promotion
Guidance For Good Practice”
16. Health Education Board for Scotland publication section: Community development approaches in primary care: options for obesity management
“Community development approaches in primary care: options for obesity management”
17. The Food Trust: Improving health, promoting good nutrition, increasing access to nutritious food and advocating better public policy
“Building Strong Communities Through Healthy Food
The Food Trust’s mission is to ensure that everyone has access to affordable, nutritious food. Founded in 1992, the Trust works to improve the health of children and adults, promote good nutrition, increase access to nutritious foods, and advocate for better public policy.”
In keeping with its organizational mission, The Food Trust evaluates the success of its programs and initiatives by its effectiveness in:
• Improving communities’ access to affordable and healthy fresh foods;
• Increasing awareness among at-risk consumers of the value of proper nutrition and its relation to individual health; and
• Effecting positive behavioral change among children and adults, as relates to healthy eating habits.
18. Healthy living : The Department of Health: Health topics: Healthy living
“Healthy living: Promoting healthy lifestyles for people in England and Wales is an important governmental responsibility. DH runs initiatives to help people quit smoking, eat better and exercise more, as well as health screening projects and training and skills programmes.”
19. Community development and its impact on health: South Asian experience — Hossain et al. 328 (7443): 830 — BMJ
“Community development and its impact on health: South Asian experience”
20. Welcome to NatPaCT
“Where PCTs grow by sharing information, experiences, and achievements.”
5. Any Community Development Approaches to Health Promotion must have the following elements
Process, Community-based Participatory Research, Capacity Building
The Community Guide – A Resource for Public Health Professionals
Step 1: Assess the primary health issues in your community
Kevin Sheridan (KS): How do you do this?
(1) Collect Data.
(2) Carry out qualitative and quantitative research – ask community members what the primary health issues are? Also ask health service providers what they are? Do these coincide or not? How do you collect this research in an increasingly cynical or over-consulted environment? – By forming a partnership with community organisations in the research area who can reach target groups. Any partnership should be equal – all partners to consensually set agenda for research. Train community members to carry out fieldwork.
(3) On basis of this research, partners (which could include health service providers) can decide on interventions. Questions to be asked should include “how would it be easier for you to change your lifestyle or get involved in changing your lifestyle?”, “how would it be easier for you to receive communications on the issues?” Community feedback should be built into any research process.
(4) It will also be essential to assess the capacity of both community organisations, academic researchers, and health service providers to carry out research, interventions, and partnership, both in terms of funding and knowledge, and to address any gaps in capacity at the earliest stage.
(5) Another point to consider is who initiates all this – obviously the focus of the work has been set in the first instance by the funders, and then perhaps by the recipients of the funds. A general call out to community organisations to suggest research and intervention projects would be useful, and if this does not produce, a more proactive engagement with community organisations will be needed. Or else, either the academic researchers, fund-recipients, or health service providers, or a combination in partnership, will need to identify geographical and/or focus groups to be approached to take the project forward.
(6) A funding pool for interventions will need to be established early, allocating a notional amount for each possible interventions, to include research, implementation, training & capacity building, evaluation, and costs of administering any partnership.
(7) Funding for interventions should be sustainable – not short-term.
Step 2: Develop measurable objectives to assess progress in addressing these health issues
KS: It is essential from the beginning to have an understanding about how success or effectiveness of any chosen interventions will be measured or evaluated. Evaluation should be built into the process and funding from the outset.
Step 3: Select effective interventions to help achieve these objectives
Step 4: Implement the selected interventions
Step 5: Evaluate the selected interventions
KS: It would be useful to develop a cross-referenced internet resource of good practice. Clear headings and navigation will have to be established. 
*Many of the guidelines for Community-based Research can also be applied to Community Development itself.
Community-based research: creating evidence-based practice for health and social change
Definition and Principles of Community-Based Research
Community-based research is becoming increasingly important in the health care field as communities are being required to take greater ownership and control over decisions affecting the health of the people in the communities. Community-based research is first and foremost about people. 
Community-based research is a collaboration between community groups and researchers for the purpose of creating new knowledge or understanding about a practical community issue in order to bring about change. The issue is generated by the community and community members participate in all aspects of the research process. Community-based research therefore is collaborative, participatory, empowering, systematic and transformative. 
Community-based research is guided and defined by the following set of principles:
• Community-Based Research is a Planned Systematic Process: Community-based research is a systematic process requiring careful planning of each stage. Most community workers begin researching by asking questions about their programs, the needs of their clients, the effectiveness of their work, whether new ideas are feasible, possible solutions to existing community problems, and so on. These issues become community-based research by formalizing the community issue into a researchable question and systematically planning for “data” collection and analysis. This formalized research process creates new knowledge upon which to base practice. It is the focus on knowledge development that distinguishes community-based research from community development.
• Community-Based Research is Relevant to the Community: Community-based research must have a high degree of relevance to the community. Community-based research focuses the research endeavour in the context of daily work activities in order to solve problems and help make those activities more effective and ultimately more satisfying. The research should result in decision-making by the community (i.e. individuals, community agencies, health units, program managers, etc.) or provide information which is in some other way directly useful to the community in which it is initiated.
• It involves asking questions such as: What are the practical problems we are facing in our work in the community? What are some questions and concerns regarding the community and health-related activities within that community? What issues are the focus of community attention? Questions such as these guide the selection of meaningful research topics and provide for the development of appropriate research questions for community-based research.
• Community-Based Research Requires Community Involvement: In community-based research, the community is actively involved in and understands the research process. The research is driven by a partnership between the community and researchers, and tends to be multi-disciplinary in nature. It is a collaborative effort involving the community at all stages of the research process. The level of community and/or researcher involvement may vary at each stage of the research, but community-based research involves joint responsibility and decision-making during every step. It requires the researcher(s) and the community stakeholders to share power and control of decision-making throughout the process. In a community-based research process, the distinction between the researcher and the researched may be minimized or eliminated. Rather than viewing participants as making “equal” contributions, in the sense of doing the same thing, community-based research emphasizes the unique strengths and contributions of the participants. It goes beyond respect and trust for the person and includes valuing the work and perspectives of each participant. It is a synergistic alliance that maximizes the contributions of each participant and it focuses on shared responsibility for the research and research process.
• Community-Based Research Has a Problem-Solving Focus: Effective community-based research is usually designed to illuminate and solve practical problems. This problem-solving focus means that the research deals with a problem or practical issue which has been identified by the community as being important to the life/health of that community. The primary objective is frequently to guide decision-making, so effective community-based research focuses on gains to the community through both the results and the research process itself. It focuses on change by creating solutions for existing problems and identifying future actions and policies that will most likely contribute to the health of the community.
• Community-Based Research Focuses on Societal Change: Unlike conventional orthodox research which focuses on prediction or understanding alone, community-based research seeks to bring about change. It is premised on the fact that engaging in a participatory, collaborative research process, and being involved the decision-making about that process is empowering and transforming. Engagement in the process allows people to develop new ways of thinking, behaving and practising.
• Community-Based Research is About Sustainability: With orthodox research and many forms of qualitative research, as the research ends, so too does the project. Community based research makes a lasting contribution to the community. This may be in the form of a new program that is ongoing, or a new service that is delivered. At times products such as manuals or workbooks may be created. One of the most significant contributions is the enhanced capacity of the community to continue to engage in future research or evaluation. The acquisition of new skills and knowledge related to research and evaluation is an essential component of community-based research.
These principles distinguish community-based research from other more orthodox forms of research including other forms of community research that are done in or for communities. In addition, these key principles situate community-based research in a different paradigm than orthodox research and determine, to a large extent, what methodologies and methods are used. 
More Key points
‘Good’ user and public involvement has the following key elements:
• Involvement becomes a core activity, not an add on or a ‘top down’ approach.
• A strategic approach is adopted across the whole organisation with strong leadership from senior management.
• There is community and organisational development – citizens need to become more informed and experienced, but organisational systems and practices also need to change.
• Partnerships are formed with other local agencies, for example, Social Inclusion Partnerships and Local Authorities, to ensure coordination and cost efficiency.
• No single approach or technique constitutes involvement of users and public.
• Various techniques can be used, which must be chosen according to the purpose of the initiative.
• The resource implications of involvement are acknowledged – for example, training, venues, crèche facilities etc.
• Tangible gains from participating can be identified and these can be demonstrated and communicated.
• Communication mechanisms are set up to ensure regular feedback in accessible formats.
• Involvement strategies need to be evaluated and constantly reviewed as part of a dynamic process of continuous learning. 
Health Service providers also need capacity building:
“We recognized that CCB could only be effective if our own organization, DTHR, had the ability to support its community partners. We could not rightfully evaluate outcomes at the community level without reflecting on our own capacity to nurture such work. We were obliged, to use Madine vanderPlaat’s insightful phrase, to “turn the evaluative gaze inward”.” 
Participatory research approaches
“With many of the methods discussed in the previous Section, control of the process is still invested in the authority or organisation. ‘Participatory research’ approaches grew out of dissatisfaction with traditional power relationships between ‘researcher’ and ‘researched’ and a demand from disabled people in particular, for more empowering models (Oliver 1996).
Community development workers in countries in South America, Africa and Asia pioneered participatory approaches in the early 1980s (Jones and Jones, 2002).
In contrast to traditional research, ‘participatory research’ approaches sought to address the gap between the concepts and models as perceived by professionals or academics and the ways in which individuals and groups in the community perceive reality. The philosophy underlying such approaches is that in order to provide anti-oppressive research fulfilling a social justice agenda, it is fundamental that the views, perceptions, direct experiences and definitions of knowledge held by people on the receiving end of services are taken account of, valued and acted upon (Brandon, 2001).
The main purpose of participatory approaches was to raise awareness and ensure that those affected by the research retained control over the whole process from the start. As Oliver (1992) argued in relation to disability research, research should not be understood as a set of technical objective procedures carried out by professionals but “part of the struggle by disabled people to challenge the oppression they currently experience in their lives”. The research question or problem, decisions about who should be involved and who the information was for, were to be decided by community groups as part of a longer term process of investigation, reflection and community action. The degree of user involvement could be affected by a number of barriers including discriminatory attitudes, access barriers, issues around resources and representativeness (Brandon, 2001).
Nevertheless, there is now evidence of research and evaluation being carried out by users and user organisations (Beresford, 2000).
People with learning disabilities for example, have been involved as originators of research ideas, advisers and consultants to research projects as well as interviewers and analysers of research findings. Examples such as the experience of the Pilton Health Project serve to confirm that the way issues are defined, articulated and tackled have a direct bearing upon the levels and quality of participation and the importance of this approach (Jones, 1998).
Builds on strengths and resources within the community.
Community based participatory research seeks to identify and build on strengths, resources, and relationships that exist within communities of identity to address their shared health concerns. These may include individual skills and assets – sometimes called human capital; networks of relationships characterised by trust, cooperation and mutual commitment – sometimes called social capital; and mediating structures within the community such as churches and other organisations where community members come together. Community-based participatory research explicitly recognises and seeks to support or expand social structures and social processes that contribute to the ability of community members to work together to improve health, and to build on the resources available to community members within those social structures.
Facilitates collaborative, equitable involvement of all partners in all phases of the research.
Community-based participatory research involves a collaborative partnership in which all parties participate as equal members and share control over all phases of the research process, e.g., problem definition, data collection, interpretation of results, and application of the results to address community concerns. Communities of identity contain many individual and organisational resources, but may also benefit from skills and resources available from outside the immediate community of identity. Thus, CBPR efforts often involve individuals and groups who are not members of the community of identity, including representatives from health and human service organizations, academia, community-based organizations, and the community-at-large. These partnerships focus on issues and concerns identified by community members, and work to create processes that enable all parties to participate and share influence in the research and associated change efforts.
Integrates knowledge and action for mutual benefit of all partners.
Community-based participatory research seeks to build a broad body of knowledge related to health and well-being while also integrating that knowledge with community and social change efforts that address the concerns of the communities involved. Information is gathered to inform action, and new understandings emerge as participants reflect on actions taken. CBPR may not always incorporate a direct action component, but there is a commitment to the translation and integration of research results with community change efforts with the intention that all involved partners will benefit.
Promotes a co-learning and empowering process that attends to social inequalities.
Community-based participatory research is a co-learning and empowering process that facilitates the reciprocal transfer of knowledge, skills, capacity, and power. For example, researchers learn from the knowledge and “local theories” of community members, and community members acquire further skills in how to conduct research. Furthermore, recognising that socially and economically marginalised communities often have not had the power to name or define their own experience, researchers involved with CBPR acknowledge the inequalities between themselves and community participants, and the ways that inequalities among community members may shape their participation and influence in collective research and action. Attempts to address these inequalities involve explicit attention to the knowledge of community members, and an emphasis on sharing information, decision-making power, resources, and support among members of the partnership.
Involves a cyclical and iterative process.
Community-based participatory research involves a cyclical, iterative process that includes partnership development and maintenance, community assessment, problem definition, development of research methodology, data collection and analysis, interpretation of data, determination of action and policy implications, dissemination of results, action taking (as appropriate), specification of learnings, and establishment of mechanisms for sustainability.
Addresses health from both positive and ecological perspectives.
Community-based participatory research addresses the concept of health from a positive model that emphasises physical, mental, and social well-being (WHO 1946).
It also emphasises an ecological model of health that encompasses biomedical, social, economic, cultural, historical, and political factors as determinants of health and disease.
Disseminates findings and knowledge gained to all partners.
Community based participatory research seeks to disseminate findings and knowledge gained to all partners involved, in language that is understandable and respectful, and “where ownership of knowledge is acknowledged”. The ongoing feedback of data and use of results to inform action are integral to this approach. This dissemination principle also includes researchers consulting with participants prior to submission of any materials for publication, acknowledging the contributions of participants and, as appropriate, developing co-authored publications.
Involves a long-term commitment by all partners.
Given the emphasis in community-based participatory research on an ecological approach to health, and the focus on developing and maintaining partnerships that foster empowering processes and integrate research and action, CBPR requires a long-term commitment by all the partners involved. Establishing trust and the skills and infrastructure needed for conducting research and creating comprehensive approaches to community change necessitates a long time frame. Furthermore, communities need to be assured that outside researchers are committed to the community for the long haul, after initial funding is over.
In summary, community-based participatory research involves a collaborative partnership in a cyclical, iterative process in which communities of identity play a lead role in: identifying community strengths and resources; selecting priority issues to address; collecting, interpreting, and translating research findings in ways that will benefit the community; and emphasizing the reciprocal transfer of knowledge, skills, capacity and power. As appropriate, such partnerships may involve individuals and groups who are not members of the community of identity, for example, representatives from health and human service agencies, or academia. However, the focus of the partnership is driven by issues and concerns identified by members of the community of identity. [18 – Paper includes policy recommendations for increasing community-based participatory research – see headings below
• Funding Research Partnerships
• Planning grants.
• Long-range funding.
• Initial and ongoing funding for infrastructure.
• Funding directly to community-based organizations as well as universities.
• Funding for comprehensive approaches that extend beyond categorical perspectives and traditional research designs.
• Grant application and review process.
• Capacity Building and Training for CBPR Partners
• Pre and post doctoral training and continuing education.
• Training programs for community members.
• Institutional support for continuing education and community service.
• Educational opportunities for members of traditionally marginalised communities.
• Benefits and Reward Structures for CBPR Partners
• Tenure and promotion process.
• Roles, responsibilities and recognition of community partners involved in
• CBPR. ]
Public Health Division, Department of Human Services, Melbourne, Victoria, Australia: Health Promotion Strategies for Community Health Services. An Evidence-Based Planning Framework for Nutrition, Physical Activity, and Healthy Weight (ebpf_nutrition.pdf)
Figure 4. contains Roles and Responsibilities in a Regional Health Promotion System. P27 
Benefits of CBPR
Overall Benefits of CBPR:
• Enhances data quality and quantity, by establishing trust.
• Moves beyond categorical approaches.
• Improves research definition and direction.
• Enhances translation and sustainability of research findings.
• Improves the community’s health, education and economics, by sharing knowledge obtained from projects.
Benefits to Schools of Public Health
• Fulfills missions of schools of public health.
• Brings together disciplines that have historically operated in their own research silo.
• Increases student interest and participation in research.
Benefits to State and local Health Departments
• Increases patient contact, primary care, and self-management.
• Facilitates development and implementation of more effective public health interventions.
• Enhances behavioural change and decreases costs to health departments.
Benefits to Public and Private Funding Institutions
• Cost effectiveness of CBPR.
• Increased trust from communities.
• Non-categorical nature allows for greater flexibility in support.
In addition to outlining benefits of CBPR, the Conclusions and Recommendations section highlights challenges facing CBPR and offers possible solutions to overcome them. Three principal challenges identified by participants included: development of university-community partnerships, institutional commitment, and training. 
Definition of CBPR
Community-based participatory research (CBPR) is committed to social change and strives to enhance health and quality of life in urban communities. CBPR is methodologically sound, rigorous research that respects and encourages varied research methods and adheres to standard ethical review processes. CBPR projects are driven by community needs and priorities to answer relevant questions, build programs, and affect public policy. Rather than a specific research method, CBPR is a widely respected ‘process’ for conducting research that values the lived experience of community members and welcomes and encourages their contributions at the levels of input (initiation of ideas), process (during data collection, analysis and interpretation phases), and outcome (implementing action-oriented recommendations).
Recognising that there are barriers to both community and academic involvement in CBPR, equitable partnerships between stakeholders are established (with clear terms of reference) to guide CBPR projects. Data generated through these projects are jointly owned and accessible to all partners. Attention to trust-building, decision-making, power and resource-sharing, and reciprocal capacity-building (where the knowledge bases and skill sets of all research partners are enhanced as a result of the research process) are expected outcomes in all CBPR projects. 
Community-partnered approaches to research
Community-partnered approaches to research promise to deepen our scientific base of knowledge in the areas of health promotion, disease prevention, and health disparities. Community-partnered research processes offer the potential to generate better-informed hypotheses, develop more effective interventions, and enhance the translation of the research results into practice. Specifically, involving community and academic partners as research collaborators may improve the quality and impact of research by:
* More effectively focusing the research questions on health issues of greatest relevance to the communities at highest risk;
* Enhancing recruitment and retention efforts by increasing community buy-in and trust;
* Enhancing the reliability and validity of measurement instruments (particularly survey) through in-depth and honest feedback during pre-testing;
* Improving data collection through increased response rates and decreased social desirability response patterns;
* Increasing relevance of intervention approaches and thus likelihood for success;
* Targeting interventions to the identified needs of community members
* Developing intervention strategies that incorporate community norms and values into scientifically valid approaches;
* Increasing accurate and culturally sensitive interpretation of findings;
* Facilitating more effective dissemination of research findings to impact public health and policy;
* Increasing the potential for translation of evidence-based research into sustainable community change that can be disseminated more broadly.
For the purpose of this PAR, community refers to populations that may be defined by: geography; race; ethnicity; gender; sexual orientation; disability, illness, or other health condition; or to groups that have a common interest or cause, such as health or service agencies and organisations, health care or public health practitioners or providers, policy makers, or lay public groups with public health concerns. Community-based organisations refer to organisations that may be involved in the research process as members or representatives of the community. While not an exhaustive list, organizations as varied as Tribal governments and colleges, state or local governments, independent living centers, other educational institutions such as junior colleges, advocacy organisations, health delivery organisations (e.g., hospitals), health professional associations, non-governmental organizations, and federally qualified health centers are possible community partners.” 
Community empowerment is a community development strategy
Community development initiatives seek to increase the capacity and resources of communities. The classic typology, formulated by Rothman and Tropman, includes social planning by outside experts, locality development or participatory development of goals and programs, and social action or advocacy. Strategies used include grassroots organising, professional organizers, coalitions, census development, problem solving, political and legislative action, and nonviolent confrontation. A more recent typology excludes social planning and promotes the value of community building from people’s strengths and assets, in addition to community organising methods.
Community empowerment is a community development strategy that derives from the work of the Brazilian educator Paulo Freire. This approach uses nontraditional educational methods to enable individuals to understand their goals independent of the prevailing social order and to develop capacities to realize these goals. Applications to health focus on enhancing awareness of needs, promoting effective problem solving, and developing capacities for implementing solutions in high-risk communities. A related strategy is media advocacy, which seeks to create leverage for broader policy change by influencing public opinion. Because the goals and approaches used in participatory community interventions cannot be fully specified in advance, evaluations rely on action research methods and qualitative or mixed methods. Some evaluations also use experimental strategies, such as group-level randomized trials. Charles and DeMaio established a framework to judge the degree of community participation. More recent reviews suggest that greater community involvement may promote intervention adoption and sustainability.
In participatory research, skills are required in developing trust with community members and leaders and dealing with differences in authority. Conflicts may arise over priorities for sustaining interventions versus identifying experimental effects and for outcomes such as neighborhood safety versus health. Community interventions shift the focus away from individuals and toward the process of engagement and impacts on communities, entailing a different measurement and assessment process.
Community research can require substantial developmental time, and the evaluation phase may be of long duration. The feasibility of achieving change in communities may be affected by political and social factors. Hence, community research requires long-term commitment to particular communities.
Strategies that can help mitigate these problems include agreeing on goals and expectations at the outset, maintaining a structured, equal partnership, using an independent community organizer, sharing expertise and resources across community organizations and researchers, educating the community about research goals and purposes, and developing financial support for community programs.
Even though community intervention research poses unique challenges, many of the conceptual, practical, and methods challenges are similar to those of practice-based quality improvement research, in which exact goals are not easily specified in advance and long-term commitment is required, and to policy research, where randomization options and availability of suitable databases for evaluation are limited. Furthermore, the conceptual and measurement frameworks underlying both policy and quality improvement research are similar: both suggest that health interventions should be embedded within local contexts and address and involve multiple stakeholders. As in community intervention research, evaluations of practice-based quality improvement interventions and public policies have revealed mixed results; however, health services research has not retreated from designing and evaluating quality improvement interventions or evaluating policy. Furthermore, with recent advances in methods, health services research has yielded a new generation of policy and quality improvement studies that are interpretable and useful to health care systems. For example, research on quality improvement interventions for depression in primary care progressed from the development of effective models within well-organized practices to effective models being implemented by community-based practices under minimal research supervision.” 
Capacity building – support and resources
When integrating health promotion principles and processes in an organisation, or when implementing a specific program, it is important to create optimal conditions for success. Capacity building for integrated health promotion enhances the potential of the system to prolong and multiply health effects and to address the underlying determinants of health. Capacity building involves the development of sustainable skills, organisational structures, resources and commitment to health improvement to prolong and multiply health gains many time over. It can occur within a specific program and as part of broad agency and system development.
Key actions areas for building capacity:
• Organisational development Partnerships Workforce development Leadership Resources
• Agencies, organisations and communities with the capacity to use a broad range of interventions and strategies to address health and wellness issues in a collaborative way through strengthened systems; program sustainability; increased problem solving abilities
• Greater capacity of people, organisations and communities to promote health
Implementing strategies from each of the key action areas should build the combined ability of the agency or partnership to:
1. Deliver appropriate program responses to particular priority health issues, including the establishment of minimum requirements in structures and skills (strengthening agency/system infrastructure).
2. Continue to deliver, transfer and adapt a particular program through a network of agencies, or to sustain the benefits achieved (program maintenance and sustainability).
3. Strengthen the generic problem-solving capability of organisations and communities to be able to develop innovative solutions, learn through experience and apply these lessons. 
Capacity Building definition
Capacity building has been defined as being (at least) three activities: (1) building infrastructure to deliver health promotion programs, (2) building partnerships and organisational environments so that programs are sustained – and health gains are sustained; and (3) building problem-solving capability. The last element is crucial. There is little value in building a system that cements in today’s solution to today’s problems. We need to create a more innovative capability so that in the future the system or community we are working with can respond appropriately to new problems in unfamiliar contexts. 
Capacity Building evidence
“…the effort that health promotion workers put into capacity-building or making their colleagues and partner organisations more interested in and more capable of engaging in effective health promotion practice. The rationale for capacity-building is simple. By building sustainable skills, resources and commitments to health promotion in health care settings, community settings and in other sectors, health promotion workers prolong and multiply health gains many times over. ”
Capacity Building definition
Different uses of the term of capacity-building appearing in the health promotion literature
1. Health infrastructure or service development Capacity to deliver particular program responses to particular health problems. Usually refers to the establishment of minimum requirements in structures, organisation, skills and resources in the health sector.
2. Program maintenance and sustainability Capacity to continue to deliver a particular program through a network of agencies, in addition to or instead of, the agency which initiated the program.
3. Problem-solving capability of organisations and communities Capacity of a more generic kind to identify health issues and develop appropriate mechanisms to address them, either building on the experience of a particular program, or as an activity in its own right. 
6. Questions of Community Empowerment & Partnership
Although Community Development and Community Based Participatory Research emphasise empowerment, it seems unlikely that full empowerment of any particular community or focus group is likely to be achieved within our existing democratic and institutional framework. Existing structures don’t really understand it or are unable to deal with it. However, it may be possible to move towards a form of empowerment through mutually educating partnerships. This will need to involve strong leadership or facilitation, and strong pre-partnership agreements.
Very good on the tensions between traditional health promotion providers & community empowerment methodology & how to incorporate the two. 
Community empowerment: UK Policy Environment
Community empowerment through their involvement in planning is central to the development of the community strategy. It is also an opportunity for communities’ perceptions of the relationship between health, health services and local authority functions to be explored. All community strategies reviewed include details of the mechanisms used to involve local communities. For many authorities new approaches are currently being developed to reach groups in neighbourhoods or populations who have been ‘hard to reach’ by traditional methods of consultation. Many authorities are also mapping other consultation and involvement activities, such as those undertaken through the NHS, to identify other sources of information. 
In many cases, the process of community consultation and involvement has been coordinated through the main local partnership responsible for the community strategy, which includes health representation. HIMP and HAZ partnerships and NHS representatives have therefore been able to participate in or influence multi-sectoral workshops, events, surveys and panels. In the better examples, local authorities combine community needs assessment data (gathered from and with key partners), with other information to set out the health and wellbeing issues for the community. 
However some of the needs assessment exercises appear to be predominantly the work of the local authority. In these cases, there is little reference to NHS consultation exercises (such as those undertaken through the HIMP or HAZ) and apparently few attempts to understand communities’ health issues in the context of other concerns or local authority functions. This tends to result in ‘health’ being variously interpreted in consultations as health services, health and social care, health behaviour and education, individual or community health. In some authorities, communities are offered a list of issues from which to select their priorities. ‘Health’ is included but not usually explained. 
Health data and national health concerns can mask other community concerns which are in fact related to health. Some authorities have found that health may appear relatively low down a list of priorities for a particular community, yet wider determinants and factors affecting immediate quality of life come first. In some authorities health is ranked very differently throughout their geographic area making it difficult to reconcile national and local priorities in the community strategy. This highlights the importance of local area plans that can articulate these differences and provide a basis for different types of support and action. 
A common duty to consult and involve communities
Central to the development of integrated local planning is the requirement to involve local communities. Councils are under a statutory duty to consult as part of the process of preparing their community strategy. However the expectation is that communities will have much more involvement than simply via consultation. ‘The involvement of local people is central to the effective development and implementation of community strategies, and key to change in the longer term’ (DETR, 2000: 50) Local strategic partnerships need to decide how community views will influence and inform their decision making process, how differences of views will be aired and resolved and how decisions will be explained to communities (DETR, 2000: 50).
‘LSPs should agree protocols to ensure that local people are involved in the design and delivery of relevant programmes which affect their communities’ (DETR, 2001: 1.21)
The NHS is also required to involve local people in planning its services and in the development and delivery of the HIMP, and to link this to broader community development processes within the LSP (as set out in the Health and Social Care Act 2001) to: ‘Ensure that the views of patients and the public are built into local planning decisions that affect people’s health e.g. through the HIMP, LSP and social services’ (DH, 2001d: Annex A).
NHS activity to involve patients and the public is expected to build on local authorities’ own mechanisms for engaging local communities and support the role and function of overview and scrutiny committees (DH, 2001d).
A joint focus on key population groups
LSPs are expected to improve the involvement of ‘hard-to-reach’ communities who have traditionally been underrepresented in consultation and community development programmes across the public sector. There is a duty on all public sector bodies to avoid discrimination between people of different racial groups and similar duties are likely in respect of gender and disabled people (DETR, 2000: 53).
HIMPs are expected to prioritise action which will support greater access and use of NHS services and care among vulnerable groups. They are also to develop joint action to improve the health of children and young people, older people, people with disabilities, black and minority ethnic groups and those in deprived communities. LSPs are similarly expected to identify ways to build capacity and training to increase the involvement of communities including disabled people, older people, youth groups, people from faith, black and minority ethnic communities, and to work with community and voluntary sectors to develop relationships within the LSP (DETR, 2001).
Actions agreed in the community strategy and the HIMP will need to be tracked to identify 
Tension between ‘bottom-up’ and ‘top-down’ programming
Health promotion often comprises a tension between ‘bottom-up’ and ‘top-down’ programming. The former, more associated with concepts of community empowerment, begins on issues of concern to particular groups or individuals, and regards some improvement in their overall power or capacity as the important health outcome. The latter, more associated with disease prevention efforts, begins by seeking to involve particular groups or individuals in issues and activities largely defined by health agencies, and regards improvement in particular behaviours as the important health outcome. Community empowerment is viewed more instrumentally as a means to the end of health behaviour change. The tension between these two approaches is not unresolvable, but this requires a different orientation on the part of those responsible for planning more conventional, top-down programmes. This article presents a framework intended to assist planners, implementers and evaluators to systematically consider community empowerment goals within top-down health promotion programming. The framework ‘unpacks’ the tensions in health promotion at each stage of the more conventional, top-down programme cycle, by presenting a parallel ‘empowerment’ track. 
Characteristics of Successful Partnerships
• Trusting relationships
• Equitable processes and procedures
• Diverse membership
• Tangible benefits to all partners
• Balance between partnership process, activities and outcomes
• Significant community involvement in scientifically sound research
• Supportive partner organization policies and reward structures
• Culturally competent and appropriately skilled staff and researchers
• Collaborative dissemination
• Ongoing partnership assessment, improvement and celebration
• Sustainable impact
Barriers to Successful Partnerships
When characteristics above are absent
Funding mechanisms, policies and procedures
o Limited funding sources
o Funding agency requirements, definitions, timelines and reviews
o Lack of funding and funding mechanisms that specifically support community as research partner
Recommendations at the level of the partnership
• Pay close attention to membership issues
• Develop structures and processes that help develop trust and sharing of influence and control among partners
• Provide training and technical assistance to partners
• Plan ahead for sustainability
• Pay close attention to the balance of activities within the partnership
• Be strategic about dissemination
• Invest in ongoing assessment, improvement and celebration 
Empowerment, Health Literacy and Health promotion – putting it all together
“Health Literacy can only be achieved through a process of health education which seeks to develop understanding of health issues and how to apply these to make decisions. However, many traditional ‘top-down’ didactic health education methods, while providing knowledge, have a negative effect of disempowering people by creating dependency on professionals and. The challenge is to provide this cognitive input through educational processes which reinforce and not undermine community confidence and power.
Self efficacy can be achieved in a variety of ways that promote self esteem and develop individual or community power over their lives and surroundings. This can be on any aspect of their lives for example action on housing, income generating, and the process of community participation or democratisation at a national level. However it can even take place at a simple level of learning new skills in farming, making ones own clothes, cooking, creative expression through music and drama. In situations where self efficacy has already been developed in a community through action on other issues not involving health, health promoters can build upon this and use shorter and simpler learning processes.
Health education using participatory learning methods provide a possible way forward through the promotion of both health literacy and self efficacy.
In recent years I have developed a data-base of evaluated health promotion interventions in developing countries. A disappointing feature of this database has been the lack of published evaluations using either qualitative or quantitative research methodologies that demonstrate that empowerment has taken placed. One approach to the lack of evaluation studies has been the criticism of methods of evaluation that work within positivist frameworks and therefore fail to adequately encompass the aims of empowerment approaches which might require alternative paradigms.
However, I suggest that the difficulty in evaluation has been the problematic and ill-defined nature of empowerment. The model proposed in this paper should make the evaluation of health empowerment a simpler process by making more explicit and hence measurable the two component parts.” 
Partnerships are strengthened by joint development of research agreements for the design, implementation, analysis, and dissemination of results 
A partnership approach to health promotion: a case study from Northern Ireland.
In recent years there has been a renewal of interest in community development and partnership approaches in the delivery of health and social services in Northern Ireland. The general thrust of these approaches is that local communities can be organised to address health and social needs and to work with government agencies, voluntary bodies and local authorities in delivering services and local solutions to problems. Since the Ottawa Charter was launched in 1986, government in Northern Ireland has stressed that community development should no longer simply be added on to key aspects of Health and Social Services, but should instead be at the core of their work. There is increasing consensus that traditional approaches to improving health and well-being, which have focused on the individual, are paternalistic and have failed to tackle inequalities effectively. Partnerships within a community development setting have been heralded as a means to facilitate participation and empowerment. This paper outlines the policy background to community development approaches in health promotion and delivery in Northern Ireland. Drawing on evidence from a case study of a community health project it highlights the benefits and difficulties with this approach. The findings suggest that partnerships can positively influence a community’s health status, but in order to be effective they require effective planning and long-term commitment from both the state and the local community. 
Senior Health Promotion Officer